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11060079 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19891 PORTAL PLZ CONTRACTOR:KRT INC PERMIT NO: 11060079 OWNER'S NAME: KUBALEK THEODOR AND ELIZABETH 21001 SAN RAMON VALLEY BLVD DATE ISSUED:06/10/2011 "'NER'S PHONE: 4082555455 SAN RAMON,CA 94583 PHONE NO:(925)556-0632 Li LICENSED CONTRACTOR'S DECLARATION ,�/ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# � CD 8 MECH r- RESIDENTIAL r— COMMERCIAL r Contractor 4fctV C_ Date `D _[(I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE&REINSTALL CLERESTORY WINDOW AT ROOF (commencing with Section 7000)of Division 3 of the Business&Professions LOCATION Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1800 Section 3700 of the Labor Code,for the performance of the work for w Wch this permit is issued. AJ� APN Number:36946005.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section / 9.18. Issued bg: Date: Signature Date � t 1 OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Own ed agent: rr become subject to the Worker's Compensation provisions of the Labor Code,I must Date: b forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION .ting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 3 ITEMS OF 9 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36946005 . 00 DATE ISSUED. . . . . . . : 06/10/2011 RECEIPT #. . . . . . . . . BS000013724 REFERENCE ID # . . . : 11060079 SITE ADDRESS . . . . . : 19891 PORTAL PLZ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : KUBALEK THEODOR AND ELIZABETH ADDRESS 19891 PORTAL PLZ CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3371 RECEIVED FROM . . . . : KENNETH TROUT CONTRACTOR . . . . . . . : KENNETH R TROUT LIC # 30426 COMPANY KRT INC ADDRESS 21001 SAN RAMON VALLEY BLVD CITY/STATE/ZIP . . . : SAN RAMON, CA 94583 TELEPHONE . . . . . . . . : (925) 556-0632 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 800 . 00 1 .00 0 . 00 1 . 00 0 .00 1BSEISMICR VALUATION 1, 800. 00 0 .50 0 . 00 0 .50 0 . 00 1WINREP EACH 8 1 . 00 380 . 00 0. 00 380 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 381 .50 0 .00 381. 50 0 . 00 al CITY OF CUPERTINO ``rj&oto, FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 19891 portal plaza bldg E DATE: 06/10/2011 REVIEWED BY: bob s. APN: 3 (p� �- BP#: VALUATION: $1,800 °PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Du lex PENTAMATION 1GENRES USE: P PERMIT TYPE: WORK remove and reinstall clearstory window at roof location SCOPE T7 NOTE. Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee.Resolution 09-051 Eff. 7'1/'10) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 0 # Window/Sliding Glass Door Suppl.PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 $380.00 1WINREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-.0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes (F) No $0.00 0 Work Without Permit? 0 Yes (D No $0.00 0 Planning Hee: $0.00 Select a Non-Residential E) Building or Structure Q Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $1.50 $380.00 TOTAL FEE.T $381.50 Revised: 04/29/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: �Qj L �. PERMIT# .57 OWNER'S NAME: 0 L E�>�D �- ONE# -��s —��` 3�-- GENERAL CONTRACTOR: N BUSINESS LICENSE# ADDRESS: C p r✓ 5�(—V ' kr'&ITY/ZIPCODE: SOV 3 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL S BCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CONSTRUCTIO . fA N PERMIT APPLICATION O Is COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 (� CUPERTINO (408)777-3228- FAX(408)777-3333-buildingacupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROTECT,ADDRESS APN# OWNER NAME �^ PHONE E-MAIL KvC3�( �K �I�t4�D�•?�c Cc�2A M STREET ADDRESS C , STATE,ZIP FAX '�� CONTACT NAMEHONE E-MAIL JJ P zo✓� ot�S- 5S"6-o 63 aIlG� S3G(�cxrAc,.Nci STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME T T LICENSE NUMBER s LICENSE TYPE BUS.LIC# J.- Lf Q z sc' g- C 3 3 0 lfa.G COMPANY NAME v T ,,/ FAX 1 f .L(v G E-MAa K+27=n/c a SBc�wQAt,. Nom- aS - S-r6-0b 2. STREET ADDRESS /� CI Y,STATE ZIP /^ alto 01 S VA LLe 4 l V!0 R 'ISI n,O GA PHONE S6` ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK SMO V K '`N -n4-4_- C(- IcFL STo25 T p0 1 't-,o FA 4T�-� c (Zoo Rip GElV�LN r EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES IF USE NLY D N S0,FT, V LUAT16N.S EXIST G NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA fVJ C. BATHROOM KITCHEN OTHER 4 - REMODEL AREA REMODEL AREA REMODEL AREA - PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA ❑ DETACH ---.-- ❑ ATTACH a D'VI I-LIN(;IfNTI l IS A SECOND LINrr ❑1'I;S SECOND STORY ❑YLS BEING ADDED'. ❑NO ADDITION' ❑NO PRI:-APPIJI A I[ON ❑ YTS IF YES.PROVIDE.COPY OF PI.ANNFR'S NAME RECfiNED BY. T JI -TOT L LUATIONr PI.ANNIN(.;AI'PI.b ❑ NO PLANMNG APPROVAL I.P1IL:R ��J By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf Ihavereatithis application and the information I have provided is correct. I have read the Description of is accurate. I agree to comply with all applicable local ordinances and state laws relating 4ui�g�s Con. I author iv Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: ll Date: e7 13 SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building ❑ OVER-THE-COUNTER 1S sutLD(NG PLAN REVIEW permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PCPBLICWORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑.I7ItEDEPT Copy of Planning Approval Letter or Meeting with Planning prior to Submittal of Building Permit application. ❑ MAJOR Dim ❑ >tfirfRGN+IMENTAL HEALTA BldgApp_2011.doc revised 03/16111